HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (9) y a
APPLICATION TFO,� S�TR ET.'E�CCAVATION PERMIT
TOINN .QI :SO TH WINDSOR
Amt. Bond Required PUBLIC 1I1I`ORI��'DEPAR'TMENT
Amt. on Fife TOW .HALL Permit �
Date of Expiration 1540 SULLIVAN AVENUE Date s •
Ins. on File OYes O No SOUTH WIND$ CT Permit Expires
Expiration Date FEEr M
Name of Firm z4tA-le-i
Address 'of Firm �� /�� aS�EG /y+/Gt �fz; Phone No. f►,2. "2"
Location of proposed work -7 :
Describe f t nature of permit re nested /0GAG.6-7 i2 to,,
Starting date 6
Call before you dig No. � d 3 Ori t�03 Approx.ra ffitime for completion
ion:
Traffic Services Control No.
Show sketch 4of proposed work or furnish To be°flped out by Town of South y,
two copies.of separate`.drawing
Pavement Cut
Indicate North
Prop. size of cut
No. cuts
,S'd 3
Amt. of Deposit $ by
Cash { ) Check #
Cut size after Perm Patch
No. Cuts
+- ....,�,.: ... Final Billing`$
Amt. Due Payee $ —
Amt. Due Town $ _
Applicant is responsible for contacting
the Police Dept. and C.S.Y.D. by date
I agree to funish to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for -any expenses incurred by the Town for maintenance or repair work in connection with this permit and that 1 am
familiar with and will ide by the rules and regulations for permits as outlined in the Town of South Windsor's Street-Cut Per Manual.
Signed: Title: �/ cua Ems+. G
D.L.L.# Date:
PERW SHALL BE ITT E AT ALL 7AJJS
!^�
APPROVED: ATEc
TOW E N !
FOR INSPECTOR:, D e work started Date. Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING `" GOLDENROD - FINANCE